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Feb 3, 2017

Diverge

The story

Like clearing your list the day before you're admitting, solving today's problems can set up trouble for tomorrow. New data shows that despite progress against major non-communicable diseases, premature mortality for some adults is on the rise.

The basics

Tobacco control and cardiovascular disease prevention and treatment are credited with large drops in global premature mortality over the past 40 years. But a 2015 report that found a post-2000 increase in premature mortality in middle-aged white men surprised the public health community.

The good news

Better treatment of HIV, heart disease, and cancer has spared premature mortality in the African American and Hispanic communities. By examining death certificates and population estimates from the US Census Bureau, researchers compared observed vs. expected deaths by age group and race. The results found that between 1999 and 2014, premature mortality decreased in both groups by > 3 % per year to the tune of hundreds of thousands of saved lives.
Lancet

The bad news

The same study showed that rates of premature mortality rose in white individuals, Native Americans, and Alaska Natives between 1999 and 2014, despite falling in countries like England and Canada. A rise in accidental deaths, primarily from drug overdoses, was the largest contributor. Many are pointing fingers at opiates: the US has the largest per capita use of prescription opiates, and the death rate from drug poisoning doubled during the study period. The excess deaths were also consistent geographically with areas known for high opiate use.

The takeaway

It's a few steps to extrapolate this study's findings to prescription opiates. But mortality increases are rare in developed countries, and some argue that the observed trend places the opiate epidemic on par with public health emergencies like HIV in the 1980's.

Say it on rounds

When you thought the medicine lounge was just cleaned yesterday

Dirt isn't the only thing that recurs when left alone. Anti-androgen therapy is used to treat prostate cancer, but whether it can delay recurrence after prostatectomy in patients with locally-advanced disease was unknown. An 18-year study of 760 patients found that the androgen receptor blocker bicalutamide improved survival (6% vs 13%) and progression to metastatic disease (15% vs 23%) relative to placebo. Gynecomastia was a notable side effect.
NEJM

When you're a tad too old for the Gardasil wave

Many things in 2017 may leave you yearning to turn back the clock. The benefits of vaccination against human papillomavirus (HPV) are well-characterized in cervical cancer prevention. But the virus is also responsible for penile, anal, and oropharyngeal cancers in men. A cross-sectional survey of 1,800 US men found a prevalence of genital HPV of 45%. Although 25% of study participants swabbed positive for at least one high-risk HPV subtype, only 10% had received an HPV vaccine, leaving an estimated 25 million vaccine-eligible men unprotected.
JAMA Oncol

When your long call falls on Super Bowl Sunday

It's hard to watch the Big Game on the resident lounge's 20-inch TV. Take solace, though, since it's harder than you think to push patients into renal failure when you order CT scans with IV contrast. A retrospective study of 18,000 ED patients found that CT-related intravenous contrast administration was not associated with increased kidney injury, regardless of baseline renal function. Contrast administration was not associated with an increased incidence of CKD, dialysis or renal transplant at 6 months.
Ann Emerg Med

Brush up

Numbers game

Half of the 7,000 internal medicine interns last year were international medical graduates (IMGs), and one fifth of applicants to the Main Residency Match were non-US citizens. A quarter of practicing physicians in the US are IMGs, and while there are 27,000 new residency spots to fill this year, US medical schools can only supply about 19,000 graduates. In 2013, 750 residency applicants were born in Iran, Iraq, Libya, Sudan, or Syria, and 2,100 applicants were from 11 Muslim majority nations.

One Step at a time

Sometimes it's hard for people of different faiths and ethnicities to find common ground. But we all can't stand ERAS and think Step 2 CS is an overpriced scam. So if you twinge a bit when you remember what it takes to get to residency, imagine applying from half a world away. Think: graduate from med school, take Step 1 and 2, apply through ERAS, and fly to the US to interview at programs. It's at least two years of time and plenty of money, and only a minority of applicants will complete the process with a successful match.

By decree

Kamal Fadlalla came to the US from Sudan to to get his butt kicked as an internal med resident in Brooklyn. Now an I-wonder-if-you've-heard-of-it executive order bars him from re-entering the US after he went home for vacation. Here’s a list of the known doctors and scientists detained or denied entry into the US over the past week. And here’s a picture of Kamal's co-residents, asking, among other things, to stop being sick-pulled over this bulls*.

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